The sloppy copy needs to be done based on this example. The patient is a man with schizophrenia, schizoaffective disorder, seizure disorder and TBI. He is a

ADMISSION INFORMATION

Student Name: Dana Priest

Date of Care:

2/25/25

Patient Initials:

CEM

Age:

31

Growth and Development Stage

Young adult:

Gender:

M

Admission Date:

1/12/2018

Reason for care needed:

DTS/DTO

Secondary Medical Diagnoses:

TBI

Surgical Hx:

Broken femur repaair

Isolation (type & reason):

None

Primary Medical Dx (describe pathophysiology, define the diagnosis, cite reference):

Schizoaffective disorder, schizophrenia and seizure disorder

List all signs and symptoms (subjective/objective data) possible with diagnosis – Highlight those your patient exhibits :

Hallucinations , delusions, depression, bizarre behavior , manic moods, personal care management , disorganized thoughts.

History of present illness:

Patient has auditory and visual hallucinations, can become aggressive very suddenly and has become a danger to self and others who trigger psychosis. Currently a 2:1 because he threw himself off of his bed and broke his arm intentionally.

ADVANCE DIRECTIVES

Living Will: Refused

Power of Attorney: Refused

Do not resuscitate (DNR) order: Refused

LABORATORY DATA:

Reason why it pertains to patient. Indicate with an “L” if low or “H” if high. (Change Norms so it is consistent for your facility’s lab data)

Test

Norms

Current Value

Date

Test

Norms

Current Value

Date

Test

Norms

Current Value

Date

Na

135-145

141

WBC

4-11.5

10.18

T3

K

3.5-5.5

4.0

RBC

3.9-5.5

4.88

T4

Cl

98-110

108

Hgb

11.5-16.5

15.7

TSH

CO2

22-30

25

Hct

35-49

47.9

PT

BUN

7-25

8

MCV

80-98

98.2

INR

Creatinine

0.4-1.4

0.94

MCH

27-34

32.1

HbA1c

Glucose

75-110

97

MCHC

32-36

32.7

OTHER

Ca

8.0 -10.5

WNL

Neuts

40-75

68.9

Globulin

2.0-4.5

Lymphs

14-46

20.90

Albumin

3.5-5.0

3.4

Monos

4-13

8.8

Bilirubin

0.2-1.5

0.7

Eos

0-7

1.0

GFR

>59.00

Baso

0-3

0.5

Describe how lab value being high or low relates to patient diagnosis:

When the numbers are either too high or too low, it can be symptomatic of a disease, or the cause of a disease. The exact arrangement of values can be linked to specific conditions.

DIAGNOSTIC TESTS

Chest X-ray: None

EKG: normal

Other abnormal reports:

Other:

Other:

Other:

Describe how diagnostic test relates to patient diagnosis:

Much in the way of blood tests, these can indicate or pinpoint a specific condition.

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